Why Women Don’t Return for Mammography Follow-up

WASHINGTON—Young women who are depressed, think of themselves as being at low risk for breast cancer, or have relatively painless mammograms are likely to skip diagnostic follow-up, according to Alexis Bakos, PhD, MSN, RN,C. In a podium presentation at the Oncology Nursing Society’s 27th Annual Congress (abstract 10), Dr. Bakos said that 25% to 60% of women do not return for follow-up and that the goal of her study was to determine who does not return, and why.

"The question we addressed was why a woman would engage in a health promoting procedure such as screening mammography but not return for diagnostic follow-up," said Dr. Bakos, a cancer prevention fellow at the National Cancer Institute, Bethesda, Maryland.

Dr. Bakos invited 243 patients from a convenience sample at two urban university medical centers to participate in the study. She reported data from the 75 women who agreed: 44 who had returned for diagnostic follow-up and 31 who had not. This was a relatively poor, urban population: 45% had less than a 12th grade education, 46% had household income less than $10,000 a year, 52% were unemployed, and 89% were black. Most (62%) had insurance coverage for their mammograms. Ages ranged from 29 to 85 years (mean, 52 years).

Study investigators interviewed all 75 women by telephone. They used Cox’s Interaction Model of Client Health Behavior to identify characteristics associated with returning for follow-up vs not returning, and reasons for returning vs not returning.

The interview questions covered social influences, previous health care experience, environmental resources, cancer fatalism (measured by the Powe Fatalism Inventory), anxiety (measured by the Trait Anxiety Inventory), depression (measured by the Beck Depression Inventory), perceived cancer screening experience, and mammography-induced pain (measured by the Painometer-Words scale).

Dr. Bakos had expected that youth (50 years old or younger), depression, and an assumption of low-risk would correlate with not returning, and multivariate analysis showed that this was the case. But women with cancer fatalism and those who had a less painful mammogram also had significantly greater odds of not returning for follow-up.

"We were surprised that women who experienced more pain during mammography were actually more likely to return for follow-up," Dr. Bakos said. "Data from the qualitative arm of the study showed that many of these women thought that ‘everyone knows’ that cancer is painful, so if the mammogram was not painful, whatever was there must not be cancer."

The investigators hope that their findings can be used to develop intervention strategies that would improve the rate of returns for diagnostic follow-up, but additional data Dr. Bakos reported at the meeting suggest that this will be difficult. Her team contacted all 31 women with abnormal mammograms who had not returned for follow-up and tried to get them to return. Only 9 agreed to schedule follow-up appointments, and 5 of those did not keep their appointments. Of the 4 who did, two were negative, one had an infiltrating ductal carcinoma, and one had microcalcifications requiring further assessment.